LITERATURE REVIEW

OVERVIEW OF MALARIA IN PREGNANCY

MALARIA

An infectious disease caused by a parasitic protozoan a blood borne parasite the natural ecology of malaria involves malaria parasites infecting successively two types of hosts: humans and female Anopheles mosquitoes. Parasitic infection of red blood cells is caused by Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae and Plasmodium ovale.

Malaria remains a great human scourge. Pregnant women and children below 5 are among the most vulnerable groups. Considering the closeness between mother and child, effective measures put in place to protect the mother from malaria could also protect the child and hence reduce the morbidity and mortality related to malaria. The World Health Organization during its Global ministerial conference on malaria in 1992 in Amsterdam, approved a number of control measures which included early diagnosis and prompt effective treatment, chemoprophylax is in susceptible groups, reduction of man vector contact, Information Education and Communication, surveillance and research.

Malaria Transmission

The geographic location of Nigeria makes the climate suitable for malaria transmission throughout the country. It is estimated that up to 97 percent of the country’s more than 150 million people risk getting the disease. The remaining three percent of the population who live in the mountains in southern Jos (the Plateau State) at an altitude ranging from 1,200 to 1,400 metres, are at relatively low risk for malaria.

Life cycle of malaria parasites

The malaria parasite life cycle involves two hosts. During a blood meal, a malaria-infected female Anopheles mosquito inoculates sporozoites into the human host. Sporozoites infect liver cells and mature into schizonts, which rupture and release merozoites. (Of note, in P. vivax and P. ovale a dormant stage [hypnozoites] can persist in the liver and cause relapses by invading the bloodstream weeks, or even years later.) After this initial replication in the liver (exo- erythrocytic schizogony), the parasites undergo asexual multiplication in the erythrocytes (erythrocytic schizogony). Merozoites infect red blood cells. The ring stage trophozoites mature into schizonts, which rupture releasing merozoites. Some parasites differentiate into sexual erythrocytic stages (gametocytes). Blood stage parasites are responsible for the clinical manifestations of the disease.

The gametocytes, male (microgametocytes) and female (macrogametocytes), are ingested by an Anopheles mosquito during a blood meal. The parasites’ multiplication in the mosquito is known as the sporogonic cycle. While in the mosquito's stomach, the microgametes penetrate the macrogametes generating zygotes. The zygotes in turn become motile and elongated (ookinetes) which invade the midgut wall of the mosquito where they develop into oocysts. The oocysts grow, rupture, and release sporozoites, which make their way to the mosquito's salivary glands. Inoculation of the sporozoites into a new human host perpetuates the malaria life cycle.

Epidemiology of Malaria

Malaria is ubiquitous in the tropical regions of the world. It is found in Central America, the Island of Hispaniola in the Carribbean, the Amazon region of South America, throughout most of Sub-Saharan Africa, parts of the Arabian peninsula, the near East, and in parts of the South Pacific. Many of these same regions also share heavy HIV/AIDS and TB burdens.33

Malaria is endemic throughout most of the tropics, approximately 3.4 billion people worldwide who are exposed annually, 1.2 billion are at high risk; the World Health Organization (WHO) states that more than 207 million developed symptomatic malaria in 2012.33 Malaria is endemic in more than100 countries on 5 continents. Ninety-nine percent of these countries had on-going malaria transmission. An estimated 3.3 billion people were at risk of malaria in 2010. Of this total, 2.1 billion at low risk (1 case per 1000 population) were living mostly in the WHO African (47%) and South-East Asia Regions (37%). Out of 99 countries with on-going malaria transmission, 43 recorded decreases of > 50% in the number of malaria cases between 2000 and 2010. Another 8 countries recorded decreases of > 25%. An estimated 655 000 persons died of malaria in 2010 eighty six percent of the victims were children under 5 years of age, and 91% of malaria deaths occurred in the WHO African Region. Approximately 300-500 million cases a year. Six countries - Nigeria, the Democratic Republic of Congo, Burkina Faso, Mozambique, Cote d'Ivoire and Mali - account for 60%, or 390,000, of malaria deaths.

Malaria is transmitted throughout Nigeria. Five ecological zones define the intensity and seasonality of transmission and the mosquito vector species: mangrove swamps; rain forest; guinea-savannah; sudan-savannah; and sahel-savannah. The duration of the transmission season decreases from year-round transmission in the south to three months or less in the north. Malaria

accounts for 60% of outpatient visits and 30% of hospitalizations among children under five years of age. It is also responsible for an estimated 300,000 deaths in children under five years of age each year and contributes to an estimated 11% of maternal mortality20

Group susceptible to malaria

All are susceptible to malaria some develop immunity after many exposures, normally after 5 years of age in an areas with high transmission of malaria. The highest risk groups are Pregnant women and children under 5 yrs old. Pregnancy reduces a woman’s immunity to malaria. Women can suffer from anaemia and give birth to low birth weight babies, which can contribute to increased infant mortality. Children under 5 have not developed enough immunity and are the most likely to suffer from cerebral malaria. Also, foreign visitors are at high risk since they have had little exposure to the disease.

Consequences of Malaria in Pregnancy

Malaria infection during pregnancy poses substantial risk to the mother, her fetus, and the neonate. The prevalence of parasitemia appears greatest in the second trimester, and susceptibility to clinical malaria may persist into the early postpartum period. Due to the endemicity and high transmission rate of malaria in Nigeria, pregnant women have acquired immunity being resident in stable malaria area and are susceptible to sub-clinical infections, which may result in adverse effects to both mother and child. It significantly contributes to anaemia in pregnancy; increases the occurrence of low birth weights; is associated with pre term deliveries, still births and perinatal mortality. It has been established that pregnancy quadruples a woman’s risk of malaria illness and doubles her risk of death.5 Preventing severe anaemia caused by malaria will lead to fewer pregnant women requiring blood transfusion thereby reducing the

risk of transfusion-related infections especially HIV and hepatitis B. The adequate control of malaria in pregnancy should lead to a better outcome of pregnancy, improve survival of mothers and reduce perinatal mortality.

Current Practices in Preventing Malaria in Pregnancy in Nigeria

Nigeria is currently implementing prevention of Malaria in Pregnancy intervention as a component of focused antenatal care services (FANC). Focused Antenatal Care provides the most practical platform for the delivery of these interventions. The key interventions that can be provided at the ANC for the prevention of malaria in pregnancy include administration of Sulphadoxine-pyrimethamine (SP) for traditional medicine (TRADITIONAL TREATMENT) under direct supervision of skilled service providers, distribution of long lasting insecticidal nets (LLINs), and appropriate case management through prompt diagnosis and effective treatment with recommended medicines.

Use of Traditional treatment

World Health Organization (WHO) estimates that about 80% of people living in Africa use traditional medicines for the management of their prevailing diseases (WHO, 2013; Marshall, 1998). Although recent advances in molecular biology and physiological chemistry have greatly enhanced the understanding and treatment of diseases, a large segment of the population still depends on traditional treatment as the preferred form of health care (Iwu & Gbodossou, 2000; Fratkin, 1996). Studies have shown that this high use of traditional treatments may be due to accessibility, affordability, availability and acceptability of traditional traditional treatments by majority of the population in developing countries (Tamuno, 2011; Akerele, Blass, Singh, Chowdhury, Kulshreshtha, Kamboj, & Bishaw 1993).

Traditional healers such as herbalists, midwives and spiritual healers constitute the main source of assistance for at least 80-90% of rural population with health problems in developing countries (WHO, 2002). The herbalists are an important national health care resource in South Africa and they are potentially valuable partners in the delivery of health care (Kubukeli, 1999). The use of traditional treatments however, is on the increase even in developed countries because of the belief that herbal remedies are safe because of their natural origin and have little or no side effects (Jacobsson, Jönsson, Gerdén, & Hägg,, 2009).

The increasing widespread use of traditional traditional treatment has prompted the World Health Organization to promotes the use of traditional treatment for health care by; supporting and integrating traditional treatment into national health systems in combination with national policy and regulation for products, practices and providers to ensure safety and quality; ensure the use of safe, effective and quality products and practices, based on available evidence; acknowledge traditional treatment as part of primary health care, to increase access to care and preserve knowledge and resources; and ensure patient safety by upgrading the skills and knowledge of herbalist (Akerele, 1987; WHO, 2005; WHO, 2008).

Traditional medicine is a vital part of health care in Nigeria. Nigeria has a rich and diverse range of flora that has been used by various ethnic communities for treatment of different diseases (Kokwaro, 2009; Gachathi, 2007). Indeed, more than 250 plants are used by various ethnic communities in Nigeria as purgatives, laxatives and emetics to treat a range of diseases (Maina, Kagira, Achila, Karanja, & Ngotho, 2013). Ethnobotanical surveys in Nigeria indicate that traditional medicine is widely practiced in the country by the different communities (Jacob, Farah, & Ekaya, 2004; Kareru et al., 2007; Njoroge & Bussmann, 2007).

In Nigeria, at least 90% of the population has used traditional treatment at least once for various health conditions (Njoroge & Kibunga, 2007). A survey conducted in Thika district, Nigeria showed that 97.45% of that population preferred to treat or manage diarrhea conditions with traditional treatment rather than conventional medicine while 52.5% first seek treatment for diarrhea from herbalists before going to the hospital (Njoroge & Kibunga, 2007). The Samburu people who inhabit the northern part of Nigeria make use of a wide range of ethno-medicinal resources comprising of about

120 plant species which are used to treat many diseases including malaria, gonorrhea, hepatitis and polio (Fratkin, 1996). Similar elaborate and rich pharmacopoeia systems have also been documented for other Nigerian communities such as the Maasai, Gusii, Luo, Abaluyia and the Kikuyu people (Gachathi, 2007; Kiringe, 2006; Sindiga, 1995).

The conventional system provides for only 30 per cent of the population, implying that more than two-thirds of Nigerians depend on traditional medicine for their primary health care needs (NCAPD, 2008). The importance of traditional treatments in Nigeria is evidenced by the fact that traditional herbalist far outnumber conventional providers. Given the estimated 40,000 herbalist and assuming a population of 38 million Nigerians, there is a herbalist-patient ratio of 1 to 950 (Maina et al., 2013).

The dependence on medicinal plants is due to lack of access to modern medical services. Although the majority of Nigerians (80 per cent) live within 5 kilometers of a health facility, medical services are not always available. Many facilities lack drugs, basic services and amenities and the cost of medicine is high. In addition, there are shortages of health professionals and the ratio of doctors to the population remains low at 15 per 100,000 (NCAPD, 2008).

Conventional Health System in Nigeria

Since Nigeria attained her independence in 1963, there has been massive growth and development of health care systems at various levels. The increased population and the demand for health care have outstripped the ability of the government to provide effective health services (Oyaya and Rifkin, 2003). However the government through the Ministry of Health (MOH) is committed to ensuring that accessible, affordable and effective health services which will promote the well-being, improve and sustains the health status of the Nigerian population is made available (MPHS-GOK, 2008; KSPAS- GOK, 2010)

Disease, ignorance, and illiteracy have been found to be the major obstacles in Nigeria. The Government of Nigeria (GoK) has supported Ministry of Health (MOH) to combat disease, but maintaining financial of MOH has undergone a lot of difficulties (KNHA, 2005). Financing and management of Health services has been a major problem in the MOH. Maintaining growing population without resources, GoK finds it challenging. Despite the reforms in the Ministry of Health that were introduced in Nigeria, people still source for health care services elsewhere (Nyamongo, 2002) and a huge population has been using traditional treatment (Lambert et al., 2011; Kiringe, 2006).

The poor constitute slightly more than half the population of Nigeria and three- quarters of the poor live in rural with Gucha district having 74% of its population living below poverty line of one US dollar per day (Chuma et al., 2009). The inaccessibility of modern medicine to Nigerian‟s population because of escalating costs has necessitated a search for alternative ways of managing illnesses (Sindiga, 1995).

In the past, modern science had considered methods of traditional knowledge as primitive and during the colonial era traditional medical practices were often declared as illegal by the colonial authorities. Consequently doctors and health personnel have in most cases continued to shun traditional practitioners despite their contribution to meeting the basic health needs of the population, especially the rural people in developing countries (WHO, 2005).

Many practitioners of conventional medicine view the increasing recognition of traditional health systems as a failure by modern medicine to satisfy the health care needs of society while some even feel threatened by a system that they view as unscientific and beyond rational categorization (Sofowora, 1996).

Analysis of various national policies related to public health and medicinal plants usage highlighted some issues for example failure to meet basic health conditions due mainly to the following factors: inadequate decentralization of health services; isolation of some rural communities; and persistence of traditional beliefs regarding pathology. This has led to underutilization of available services in health centers and high cost of services provided by hospitals in relation to the income of the rural population. In addition to recommending measures to raise consumer awareness, the guidelines suggest that governments establish standards of practice, treatment and training for complementary medicine (WHO, 2005). They also encourage collaborations between conventional and traditional care providers to improve results and help reform the health sector in developing nations (Akerele, 1992).

Traditional treatment Practice

Human beings have engaged in the development of detailed botanical pharmacopoeia through trial and error with a view to combat illnesses that were often specific to their localities. The practice of traditional treatment in Nigeria unlike Asia has largely been considered primitive by the elite (Kigen, Ronoh, Kipkore, & Rotich, 2013).

The high dependence on traditional treatment in most African populations is partly attributed to traditional beliefs and lack of reliable modern health care (Sindiga, 1995). The decision to engage with a particular medical channel is influenced by a variety of socio-economic variables, sex, age, gender, religion, the type of illness, access to services and perceived quality of services (Tipping & Segall, 1995).

Traditional treatment is commonly chosen by people to treat common diseases and chronic diseases. Many Nigerians believe in the potency of traditional treatment, even when they can access modern medicine (Kigen et al., 2013). In many cases they would choose to combine both herbal and modern medicine, especially if they are afflicted with chronic ailments such as HIV/AIDS, hypertension, infertility, cancer and diabetes (Kigen et al., 2013). According to a study done in Taiwan, it was established that patients used traditional treatment for muscular and joint problem for lung or respiratory complain while others to promote wellness and quality of life (Daly, Tai, Deng, & Chien, 2009).

Source of Knowledge on Traditional treatment use

In most Nigerian communities, perhaps due to cultural reasons, the practice was considered a family affair and the practitioner would prefer to transfer the talent to one close relative (Kigen et al., 2013). Similarly, the herbalist reported that knowledge about traditional treatment is passed down from parents, relatives and friends and may not necessarily require any formal education (Enwere, 2009).

Family expectations of receiving treatment from herbalist are one of the reasons for continuous dependence on traditional treatment. In addition the influence of relatives, friends and neighbors on health-care seeking behavior for traditional treatments has been reported globally in adults and children, 51.4% in the United States (Bennett & Brown, 2000) and 60%-86% in developing countries (Danesi & Adetunji, 1994; Oshikoya et al., 2008; Lanski et al., 2003). Moreover, studies have shown that media such as newspapers advertisements, television and radio, play an important role in creating awareness (Bennett & Brown, 2000).

Attitude towards Traditional treatment

Traditional treatment has been used for centuries and it is claimed to have gained acceptance because of its effectiveness. Studies have shown that the attitudes of patients have a strong association with the utilization of traditional treatment. A study done in South Africa among Academic and Administrative University staff indicates that patients‟ have positive attitude towards traditional treatment, with better clinical care and positive outcome after treatment using traditional treatment (van Staden & Joubert 2014).

Studies carried out so far indicate that this increase in use of herbal remedies for management of health conditions could be as a result of people perceiving them as natural and therefore safe, increase in cost of contemporary medicine and increase in advertisement of herbal remedies. In a study carried out in Murang'a District, Nigeria among people with diabetes mellitus showed that there was association between the perceptions people have on herbal remedies and use of traditional treatment (Mwangi, 2003).

Similarly, in Ethiopia, a study done to evaluate the perception and practices of modern and traditional health practitioners about traditional medicine indicated that there is a perception that the conventional health system is inadequate to diagnose and treat certain diseases like evil eyes, epilepsy and gonorrhea (Gatachew, et al., 2002).

Phyto-medicine products

Over the past decade, interest in drugs derived from plants has greatly increased. It is estimated that about 25% of all modern medicines are directly or indirectly derived from plants (Cragg & Newman, 2001). The potential of plants as source of conventional drugs exists for example reserpine, an alkaloid was the first anti- hypertensive drug that was isolated from the roots of Rauwolfia serpentine (Apocynaceae) in 1952 (Pandey, Debnath, Gupta, & Chikara, 2011). Safety and effectiveness of some of the medicinal plants have been evaluated leading to new antimalarial drugs developed from the discovery and isolation of artemisinin from Artemisia annua L., a plant used in China for almost 2000 years (WHO, 2008).

It is clear that there is a lot of potential in Nigerian traditional treatment judging from the published laboratory results from the screening of the plant extracts that have been analyzed in various institutions. The following Nigerian medicinal plants; Albizia gummifera, Boscia salicifolia,, Rhus natalensis, Vernonia lasiopus, Rhamnus prinoides, Pentas longiflora and Ficus sur among others, have shown antiplasmodial activity hence effective in malaria treatment (Gathirwa et al., 2007; Rukunga et al., 2007; Muthaura et al., 2007; Muregi et al., 2003). Similarly, the aqueous extract of Carissa edulis, Prunus Africana and Melia azedarach have demonstrated the potential anti-viral activities at non-cytotoxic concentrations (Tolo et al., 2008). Other studies have shown that water extracts of Warburgia ugandensis have antifungal activity against Candida albicans (Olila et al., 2001) and also antileishmanial activity (Ngure et al., 2009). Similary, pentacyclic triterpenes isolated from Acacia mellifera have demonstrated antimicrobial activity (Mutai et al., 2009) among other Nigerian medicinal plants.

However, there is need to document the information from herbalists in order to provide a database for future research and potential for development of new drugs. Information obtained from ethno-medicine is now being put on a scientific basis and is therefore important to investigate the knowledge, attitudes and practice on utilization.

Knowledge on Malaria

A study conducted in Rivers41 found that more than three quarters (76.4%) of the women had correct knowledge that malaria is caused by exposure to mosquito bites. There were however some respondents with misconceptions that malaria resulted from working in the sun (11.5%), eating too much of palm oil (4.7%) and witchcraft (1.5%). Most of the women (71.4%) equally had knowledge that malaria could cause some harm during pregnancy to the mother or fetus such as abortion, still births, or low birth weight.41 Nigerian Malaria indicator survey (NMIS) found that knowledge of malaria is almost universal. Ninety-four percent of women have heard of malaria, a statistic that varies little by background characteristics. More than 90 percent of women in all groups have heard of malaria, except in North Central, where only 88 percent of women report having heard of malaria.43 Also in the same study eighty-two percent of women knew that malaria is caused by mosquitoes, while 27 percent said malaria is caused by dirty surroundings, and 12 percent said malaria is caused by the presence of stagnant water. Six percent of women said that eating certain foods caused malaria, and eight percent of women responded that they did not know what caused malaria.

Traditional treatment of Malaria in Pregnancy

Traditional treatment of malaria during pregnancy is a strategy where all pregnant women are given a full curative dose of herbal supplements at least twice during pregnancy, regardless of whether they have malaria. Starting as early as possible in the second trimester, herbal treatments with herbs remains effective in preventing the adverse consequences of malaria on maternal and fetal outcomes in areas where a high proportion of Plasmodium falciparum parasites carry quintuple mutations associated with in vivo therapeutic failure to Sulphadoxine-pyrimethamine

Knowledge of Traditional medicine of Malaria in Pregnancy (Traditional treatment)

The level of knowledge that the pregnant woman has about Traditional treatment will inform her on whether to regularly attend the ANC to receive HERBS or not and this will affect the uptake of traditional treatment. Their best and most lively source of this knowledge is at the ANC where health workers are supposed to educate them. A study conducted in Uganda found that nearly all respondents (99.4%) had heard about HERBS prior to the interview. Regarding knowledge on the role of herbs as used during pregnancy, 57% mentioned prevention of malaria in mother or unborn baby while 15.4% thought it was used to treat malaria. About 26% and 0.9% respectively, did not know its indication or cited other reasons not related to malaria46. It is estimated that in 2007, 25% of pregnant women received at least 1 dose of traditional treatment. The importance of providing Traditional treatment under direct observation, as directly observed treatment, was stressed. It was also suggested that WHO recommendations should state that all possible efforts should be made to avoid HERBS use as monotherapy for malaria treatment in order to protect its efficacy for Traditional treatment. In another study,47 it was found that some participants perceived malaria prevention as a component traditional medicine homes, but most did not. Very few participants in rural areas referred to receiving anti-malarial drugs, LLINs, or rapid diagnostic testing of malaria with ANC services. Participants did not appear to clearly understand the difference between chemoprophylaxis (prevention of malaria through medication) and the specific treatment they have to take in the event of an episode of malaria. A study conducted in south west Nigeria48 found that about half [109 (52.2%)] of the respondents, said they have heard about Traditional treatment. Twenty six of the 109 (23.9%) who have heard about Traditional treatment were able to give a good definition of traditional treatment and sixty-three (57.8%) said Traditional treatment can be given to pregnant women. About two thirds of those that have heard of traditional treatment (73/109; 67.0%) knew that HERBS is the recommended drug for Traditional treatment. Using the different brand names of HERBS in the market, 13(17.8%) identified Fansidar®, 18(24.7%) identified Amalar, 42(57.5%) identified malareich which was the major brand given to them in the ANC clinic as drug used for Traditional treatment. Forty nine (67.1%) of those who mentioned herbs knew the correct dose of herbs for Traditional treatment.

A study from Kano46 found that Majority 216 (90.4%) of the respondents said that they have heard about Traditional treatment. The sources of information on Traditional treatment included electronic media 193 (89.4%) and health workers during antenatal clinic 16 (7.4%). All respondents knew the local itsekiri name for malaria and they all knew that it was transmitted by mosquito bite. On whether there are different types of mosquitoes, only a few of the women who happened to be teachers or health workers knew that there are different types of mosquitoes transmitting different diseases. The majority thought that all mosquitoes transmit malaria. Using a combination of respondents’ knowledge of malaria and traditional treatment, 75 (31.2%), 137 (57.6%), and 27 (11.2%) of the respondents had good, fair, and poor knowledge of traditional treatment, respectively.

CHAPTER SUMMARY

In this review the researcher has sampled the opinions and views of several authors and scholars on malaria, its and its effect, traditional treatment practice and the treatment of malaria during pregnancy. The works of scholars who conducted empirical studies have been reviewed also. The chapter has made clear the relevant literature.